Web BPR: Requesting and Receiving Claim Status Information

Latest Validation: May 21, 2012 BPR: Version 1.4

High Impact Best Practices: 8 of 9 met 1 is not met.

The Patient Control Number is not included as a field in the list of patients that match the search criteria that is entered. Having this number in the list is important so that providers can quickly select the specific claim that they want to see without having to go back and forth to the detail screen. Patient Control Number is in the detail Claim information once a claim in selected. Action to be taken: Aetna has no current plans to include Patient Control Number in the Search Results list

Medium Impact Best Practices: 2 of 2 met

Usability Score: 3.2 on a 5.0 scale

Latest Validation: August 2012 BPR: Version 1.4

High Impact Best Practices: 8 of 9 are always met (1 is sometimes not met).

In some but not all cases, an explanatory remark code is provided on the web site without an accompanying description. Extra work, e.g. call to customer service, is required if the provider doesn't know the meaning of the remark code.

Action to be Taken: Cigna is working on a fix to be completed 1Q2013

Medium Impact Best Practices: 2 of 2 met

Usability Score: 4.0 on a 5.0 scale

Notes:

1. In some but not all cases, searching by Patient Control Number does not return the corresponding claim(s).Action to be Taken: Cigna is working on a fix. Completion date TBD

2. When claim payment/reimbursement is identified as member responsibility and payment is made from a member's Reimbursement Account (Health Saving's Account (HSA) or Health Reimbursement Account (HRA), the web site indicates claim processed AND a paid date is noted. This is a correct display of status information, though confusion can result as this is different from the more common situation when the status information is EITHER claim processed (meaning claim has been adjudicated and no reimbursement from member's benefit) OR a paid date (meaning claim has been adjudicated and payment made.)

Latest Validation: August 2012 BPR: Version 1.4

High Impact Best Practices: 7 of 9 are met (2 not met).

1. The reason for a claim denial is not provided on the web site.

2. There is inconsistency between the web site and customer services as the reason for a claim denial was available from customer service. (Differences between web site information and customer service reinforce the practice of making phone calls.)

Action to be Taken: GHC recognizes these gaps, which will be corrected when we move to our new claims processing system's Web portal (implementation date TBD).

Medium Impact Best Practices: 2 of 2 met

Usability Score: 3.9 on a 5.0 scale

Latest Validation: June 27, 2012 BPR: Version 1.4 (Amended Dec 17, 2012)

High Impact Best Practices: 7 of 9 are met (2 not met).

The Patient Control Number and the Health Plan Claim Number are not included as fields in the summary list of patients that match the search criteria that is entered. Having these numbers in the list is important so that providers can quickly select the specific claim that they want to see without having to go back and forth to the detail screen. Patient Control Number and Health Plan Claim Number are in the detail Claim information once a claim is selected. Action to be Taken: This is being considered as a future web site enhancement.

• For some zero payment claims and some denied claims, the status information may not always contain sufficient level of detail. Phone calls may be required to get up to date information. Action to be Taken: This is being considered as a future web site enhancement.

Medium Impact Best Practices: 1 of 2 met (1 not met)

• The summary results list on the web site does not clearly indicate when an entry in that list is a combined claim (rather than the two submitted claims for the same provider and date of service that hit a bundling edit). Without knowing that claims are combined, providers do extra research including calling Customer Service to find out what happened with their submitted claims.

  Action to be taken: Explore possibility of highlighting combined claims.

Usability Score: 4.2 on a 5.0 scale

Latest Validation: June 26, 2012 BPR: Version 1.4

High Impact Best Practices: 8 of 9 are met (1 not met).

The Patient Control Number is not included as a field in the list of patients that match the search criteria that is entered. Having this number in the list is important so that providers can quickly select the specific claim that they want to see without having to go back and forth to the detail screen. Patient Control Number is in the detail Claim information once a claim in selected. Action to be taken: None at this time.

Note - When a claim is adjusted, there may be a delay before the web site (Provider Center) is updated. Adjustments are made manually to the claims processing system before the claim is manually released to the Provider Center. Until the adjusted claim is manually released, Customer Service will have access to more up to date status information.

Medium Impact Best Practices: All met

Usability Score: 4.3 on a 5.0 scale

Latest Validation: October 2012 BPR: Version 2.8 Worksheet Version: 092912a

High Impact Best Practices: 17 of 17 are met.

Note: For some providers, it may appear as though reversals and corrections for a claim are not processed and reported correctly. However, research has indicated these situations are likely due to the provider's billing system rather than to United Healthcare's processing. For reversals and corrections to process correctly, the provider's claim number of the corrected claim needs to be the same as the provider's original claim number. Some Provider systems (such as Epic) increment the provider's claim number each time they send a corrected claim. United Healthcare's processing system treats this corrected claim as a new claim, since the two have different claim numbers

Medium Impact Best Practices: 11 of 11 are met.